Morning Report ,

Tuesday th November 2015

On Duty:
Rivan
Aprillia
Merry
Yasinta
Bima
Dennis

DPJP:
Dr. Arthur Mawuntu, SpS
 Statistic
1. Mrs. JG/ 45 yo/ Dx : BPPV
2. Mr. ME / 59 yo / Dx : Migraine + Hypertensi gr.2
3. Mr. LD/ 47 yo/ Dx : Tetraparese UMN ec SCI ASIA
IMSOP Gr. C
4. Mrs. SJ / 54 yo / Dx : Vertigo post trauma
5. Mrs. MP / 34 yo/ Dx : Reattack CVD SI onset day
3rd
6. Mr. DH/ 49 yo/ Dx : Unconsiousesness ec Sepsis
7. Mr. TR /24 yo / Dx : comotio cerebri
8. Mr. KG /16 yo / Dx : comotio cerebri
9. Mr. RA /38 yo / Dx : Moderate Head Injury +
Susp. Fr Basis Cranii
10.Ms. MK / 1 yo / Dx: Mild Head Injury
 History Taking
Male 47 yo admitted to hospital with weakness in
all extremity since 10 hour before admission
10 hour BEFORE ADMISSION HOSPITAL ADMISSION

Patient got accident while he Crampt in all extremity and

was down and his face bumped a following weakness in all
ground extremity (+)
Crampt in all extremity and Headache (+)
following weakness in all
extremity (+) 30 minute after
accident
Consciousness and complained
of headaches (+)
History of vomiting(_)
Blood from nose and ears(-)
Seizure (-),Fever(-)
Alcohol (+)
 History of Past Illness
History of trauma (+) 1 year ago
Hypertensi(+) not take medicane
regulary, DM (+),cholesterol (+) , urid
acid (+)
 Physical Examination
General examination:
General condition: moderate, Consciousness : compos
mentis
BP: 130/80 HR: 78 x/m reg, RR: 20x/m , T: 36,5 C VAS 6
Conjunctiva : pale (-/-), sclera ikteric (-/-)
Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -
murmur
Back : gibbus (-)
Abdomen : flat, normal turgor, peristaltic normal
Extremities : warm acral
 Neurologic examination
GCS E4M6V5(15) PERRL +/+ 3mm / 3mm
Meningeal Sign: Nuchal rigidity (not
evaluated), Laseque (-/-) , Kerniq(-/-)
Cranial Nerves: NII N.XII paresis (-)
FODS: colour orange, Cupping (+), a:v = 2:3
Motoric State : tetraparesis UMN
MS : 3333/3333 MT : FR : ++ ++ PR :
--
3322/2233 ++ ++
--

Sensoric State : hipestesi at C-5 dermatoma

Autonomic State : incontinentia urine et alvi
(-)
 ECG expertise
In Normal Range
 Laboratory Examination
Hb : 14,2
MCV : 92
MCH : 30
Ht : 42,2
WBC : 10.200
PLT : 276.000
RBC : 4,25x106
GDS: 89
Cr : 0,8
Ur : 30
Na :139
K : 3,3
Cl :107
X-Ray Chest
 Dx
Tetraparesis ec compressed fracture
C2-3, C5
Hipokalemia mild
 Planning
Bed rest
Collar Neck Rigid
IVFD NaCl 0,9% 500cc 14tpm
Inj Methylprednisolone 3x500mg iv
Inj Ranidine 2x50mg iv
Inj Ketorolac 1amp if severe pain iv
Paracetamol 3x500mg po
Gabapentin 2x300mg po
Lactulax syr 0-0-CII
Consult to Orthopaedic department
Consult to Rehabilitation department
MRI Cervical + contrast